Page 18

WDHD-2015-handbook-final

The Family Practitioner’s Approach to Heartburn, continued.
upper GI symptoms using PPIs was related to their relatively high
cost and the large proportion of the health budget they took up.
With the availability of cheap generics this is no longer an issue.
The role of surgery, essentially fundoplication, is not as prevalent
in the UK as in many other European countries and the USA and
is normally initiated by a gastroenterologist with a referral to a
surgeon, rather than directly from a PCP.
However, whilst the cost and use of PPIs in the initial management
of heartburn is not a major issue for PCPs, there are concerns
about their long-term use because of possible significantly detrimental
side effects. A substantial proportion of the population is
taking PPIs, ranging between 2-15% of the Western population
depending on definitions of long-term 7 and the numbers are
increasing. In many parts of the world, PPIs are available without
a prescription and the rates of usage are even higher. It is hard to
determine if there is a strong element of over-prescribing by PCPs
because of the widened indications for them – essentially concurrently
for gastroprotection with NSAIDs and aspirin. With an
increasing elderly population taking such drugs, there has been a
steep rise in the use of long-term PPIs. In the UK, PCPs are required
to audit their long-term prescribing and to monitor patients
for appropriate clinical indications. At the same time, it would
appear that patients with GORD are relatively adherent to their
medication, even if symptom control is variable, and that severe
symptoms and Barrett’s esophagus are associated with increased adherence
8. However, few data are available on the rate of success
of strategies to reduce or stop treatment for heartburn or GORD
specifically.
In summary, a number of problems and questions remain in relation
to the PCPs’ responses to heartburn and its management.
These include whether the interpretation of the presenting problem
was accurate; if the presenting symptom was the issue that
needed chief attention or if there were other factors that were key.
Additionally, is the level of control of symptoms considered satisfactory
and what might be gained from a secondary care opinion?
Heartburn remains, essentially, a primary care problem and its interpretation
and context within a mix of other symptoms creates a
complex issue. What has changed is that it is much less likely to be
investigated than in previous years and there is less optimism about
the power of PPIs to solve the problem. Nonetheless, the size of
the problem is growing and vigilance is needed in at risk groups.
References
1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. Global
Consensus Group. The Montreal definition and classification
of gastroesophageal reflux disease: a global evidence-based
consensus. Am J Gastroenterol 2006;101:1900-20.
2. Raghunath AS, Hungin AP, Mason J, Jackson W. Symptoms
in patients on long-term proton pump inhibitors: prevalence
and predictors. Aliment Pharmacol Ther 2009;29:431-9.
3. Mainie I, Tutuian R, Shay S, Vela M, Zhang X, Sifrim
D, Castell DO. Acid and non-acid reflux in patients with
persistent symptoms despite acid suppressive therapy: a
multicentre study using combined ambulatory impedance-pH
monitoring. Gut 2006;55:1398-402.
4. Dent J, Vakil N, Jones R, Bytzer P, Schöning U, Halling K,
Junghard O, Lind T. Accuracy of the diagnosis of GORD by
questionnaire, physicians and a trial of proton pump inhibitor
treatment: the Diamond Study. Gut 2010;59:714-21.
5. Heading R, Thomas E, Sandy P, Smith G, Fass R, Hungin P.
Discrepancies between upper GI symptoms described by those
who have them and their identification by conventional medical
terminology: a survey in four countries. Abstract OP398,
UEGW 2015, Vienna.
6. Ness-Jensen E, Lindam A, Lagergren J, Hveem K. Changes in
prevalence, incidence and spontaneous loss of gastro-oesophageal
reflux symptoms: a prospective population-based cohort
study, the HUNT study. Gut 2012;61:1390-7.
7. Haastrup P, Paulsen MS, Begtrup LM, Hansen JM, Jarbøl
DE. Strategies for discontinuation of proton pump inhibitors:
a systematic review. Fam Pract 2014;31:625-30.
8. Hungin AP, Hill C, Molloy-Bland M, Raghunath A. Systematic
review: Patterns of proton pump inhibitor use and adherence
in gastroesophageal reflux disease. Clin Gastroenterol
Hepatol 2012;10:109-16.
World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 18